Histopathologic review of prostate biopsies from patients referred to a comprehensive cancer center: correlation of pathologic findings, analysis of cost, and impact on treatment

Clinical and Financial Implications of Second-Opinion Surgical Pathology Review

OBJECTIVES

Second-opinion pathology review identifies clinically significant diagnostic discrepancies for some patients. Discrepancy rates and laboratory-specific costs in a single health care system for patients referred from regional affiliates to a comprehensive cancer center ("main campus") have not been reported.

METHODS

Main campus second-opinion pathology cases for 740 patients from eight affiliated hospitals during 2016 to 2018 were reviewed. Chart review was performed to identify changes in care due to pathology review. To assess costs of pathology interpretation, reimbursement rates for consultation Current Procedural Terminology billing codes were compared with codes that would have been used had the cases originated at the main campus.

RESULTS

Diagnostic discrepancies were identified in 104 (14.1%) patients, 30 (4.1%) of which resulted in a change in care. In aggregate, reimbursement for affiliate cases was 65.6% of the reimbursement for the same cases had they originated at the main campus. High-volume organ systems with low relative consultation reimbursement included gynecologic, breast, and thoracic.

CONCLUSIONS

Preventable diagnostic errors are reduced by pathology review for patients referred within a single health care system. Although the resulting changes in care potentially lead to overall cost savings, the financial value of referral pathology review could be improved.

Histopathological re-evaluations of biopsies in prostate cancer: a nationwide observational study

BACKGROUND

Grading prostate biopsies has an important role in determining treatment strategy. Histopathological evaluations suffer from interobserver variability and therefore biopsies may be re-evaluated.

OBJECTIVE

To provide insight into the extent of, characteristics associated with and clinical implications of prostate biopsy re-evaluations in daily clinical practice.

METHODS

Patients diagnosed with prostate cancer (PCa) by biopsy between October 2015 and April 2016 identified through the Netherlands Cancer Registry were included. The proportion of re-evaluations was assessed and characteristics were compared between patients with and without biopsy re-evaluation. Interobserver concordance of ISUP grade and EAU prognostic risk classification was determined by calculating Cohen's kappa.

RESULTS

Biopsy re-evaluation was performed in 172 (3.3%) of 5214 patients. Primary reason for re-evaluation in patients treated with curative intent was referral to another hospital. Most referred patients treated with curative intent (n = 1856) had no re-evaluation (93.0%, n = 1727). Patients with biopsy re-evaluation were younger and underwent more often prostatectomy compared to patients without re-evaluation. The disagreement rate for ISUP grade was 26.1% and interobserver concordance was substantial (κ-weighted = 0.74). Re-evaluation resulted in 21.1% (n = 14) of patients with localised PCa in a different prognostic risk group. More tumours were downgraded (57.1%) than upgraded (42.9%). Interobserver concordance was very good (κ _weighted = 0.85).

CONCLUSION

Pathology review of prostate biopsies is infrequently requested by clinicians in the Netherlands but in a non-negligible minority of patients with localised PCa the pathology review led to a change in prognostic risk group which might impact their treatment.

Improved quality of patient care through routine second review of histopathology specimens prior to multidisciplinary meetings

AIM

Double reading may be a valuable tool for improving quality of patient care by identifying diagnostic errors before final sign-out, but standard double reading would significantly increase costs of pathology. We assessed the added value of intradepartmental routine double reading of histopathology specimens prior to multidisciplinary meetings.

METHODS

Diagnoses, treatment plans and prognoses of patients are often discussed at multidisciplinary meetings. As part of the daily routine, all pathology specimens to be discussed at upcoming multidisciplinary meetings undergo prior intradepartmental double reading. We identified all histopathology specimens from 2013 that underwent such double reading and determined major and minor discordance rates based on clinical relevance between the initial and consensus sign-out diagnoses.

RESULTS

We included 6796 histopathology specimens that underwent double reading, representing approximately 8% of all histopathology cases at our institution in 2013. Double reading diagnoses were concordant in 6566 specimens (96.6%). Major and minor discordances were observed in 60 (0.9%) and 170 (2.5%) specimens, respectively. Urology specimens had significantly more discordances than other tissues of origin, Gleason grading of prostate cancer biopsies being the most frequent diagnostic problem. Furthermore, premalignant and malignant cases showed significantly higher discordance rates than the rest. The vast majority (90%) of discordances represented changes within the same diagnostic category (eg, malignant to malignant).

CONCLUSIONS

Routine double reading of histopathology specimens prior to multidisciplinary meetings prevents diagnostic errors. It resulted in about 1% discordant diagnoses of potential clinical significance, indicating that second review is worthwhile in terms of patient safety and quality of patient care.

Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology: Guideline From the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology

CONTEXT

Additional reviews of diagnostic surgical and cytology cases have been shown to detect diagnostic discrepancies.

OBJECTIVE

To develop, through a systematic review of the literature, recommendations for the review of pathology cases to detect or prevent interpretive diagnostic errors.

DESIGN

The College of American Pathologists Pathology and Laboratory Quality Center in association with the Association of Directors of Anatomic and Surgical Pathology convened an expert panel to develop an evidence-based guideline to help define the role of case reviews in surgical pathology and cytology. A literature search was conducted to gather data on the review of cases in surgical pathology and cytology.

RESULTS

The panel drafted 5 recommendations, with strong agreement from open comment period participants ranging from 87% to 93%. The recommendations are: (1) anatomic pathologists should develop procedures for the review of selected pathology cases to detect disagreements and potential interpretive errors; (2) anatomic pathologists should perform case reviews in a timely manner to avoid having a negative impact on patient care; (3) anatomic pathologists should have documented case review procedures that are relevant to their practice setting; (4) anatomic pathologists should continuously monitor and document the results of case reviews; and (5) if pathology case reviews show poor agreement within a defined case type, anatomic pathologists should take steps to improve agreement.

CONCLUSIONS

Evidence exists that case reviews detect errors; therefore, the expert panel recommends that anatomic pathologists develop procedures for the review of pathology cases to detect disagreements and potential interpretive errors, in order to improve the quality of patient care.

Improved cytodiagnostics and quality of patient care through double reading of selected cases by an expert cytopathologist

Double reading may be a valuable tool for improving the quality of patient care by restoring diagnostic errors before final sign-out, but standard double reading would significantly increase costs of pathology. The aim of this study was to assess the added value of routine double reading of defined categories of clinical cytology specimens by specialized cytopathologists. Specialized cytopathologists routinely re-diagnosed blinded defined categories of clinical cytology specimens that had been signed out by routine pathologists from January 2012 up to December 2013. Major and minor discordance rates between initial and expert diagnoses were determined, and both diagnoses were validated by comparison with same-site histological follow-up. Initial and expert diagnoses were concordant in 131/218 specimens (60.1 %). Major and minor discordances were present in 28 (12.8 %) and 59 (27.1 %) specimens, respectively. Pleural fluid, thyroid and urine specimens showed the highest major discordance rates (19.4, 19.2 and 16.7 %, respectively). Histological follow-up (where possible) supported the expert diagnosis in 95.5 % of specimens. Our implemented double reading strategy of defined categories of cytology specimens showed major discordance in 12.8 % of specimens. The expert diagnosis was supported in 95.5 % of discordant cases where histological follow-up was available. This indicates that this double reading strategy is worthwhile and contributes to better cytodiagnostics and quality of patient care, especially for suspicious pleural fluid, thyroid and urine specimens. Our results emphasize that cytopathology is a subspecialization of pathology and requires specialized cytopathologists.

Results of central pathology review of prostatic biopsies in a contemporary series from a phase III, multicenter, randomized controlled trial (SHIP0804)

To investigate contemporary rates of variation in the biopsy Gleason grading in prostate cancer, between local and central pathologists, based on central review of the pathological slides from Seed and Hormone for Intermediate-risk Prostate Cancer (SHIP) 0804, a phase III, multicenter, randomized, controlled study. From April 2008 to May 2011, 18 Japanese institutions participated. All H&E slides were reviewed independently, without clinical information, and a tumor grade was assigned according to the modified Gleason grading system proposed by the International Society of Urological Pathology (ISUP). Prostate biopsy specimens of 642 cases were available for evaluation. An exact concordance rate of Gleason score (GS) between local and central pathologists was determined to be 65.3%; with the under-grading and over-grading of grades to be 14.6% and 20.1%, respectively. The central review resulted in numbers of tumor-bearing cores reassigned in 99 of 616 cases in which such information by the local pathologists was available (16.1%). Discordance in biopsy Gleason grading was still found in one third of the cases in the SHIP0804 study. This information is valuable in extrapolating the diagnostic error range in contemporary clinical studies conducted without central pathological review.

The clinical impact of pathological review on selection the treatment modality for localized prostate cancer in candidates for brachytherapy monotherapy

AIM

To evaluate the impact of pathological review by pathologist with genitourinary expertise (PGU) on treatment modality of localized prostate cancer, we analyzed Gleason grade (GG) migration and the final treatment decision in a cohort of patients designated for permanent prostate brachytherapy (PPB).

METHODS

From February 2005 to July 2010, a total of 247 patients with localized prostate cancer diagnosed by local community hospitals were referred to our hospital for PPB monotheray. All pathologic slides of prostate biopsies were reviewed by a single PGU. Patients ultimately selected their treatment modality from our recommendations based on the review. Indication for PPB monotherapy was the NCCN classification of patients as good or intermediate risk. In addition, patient with Primary GG 4 was regarded as unadapted case.

RESULTS

Six cases were reinterpreted as no cancer (2.4%). GG change occurred in 94 cases (38.1%) of which 77 (81.9%) were upgraded and 17 (18.1%) downgraded. Of the total 247 patients, 86 (34.8%) changed therapies and 30 (12.1%) did so based on the pathologic slide review.

CONCLUSIONS

Pathological review of biopsy specimens is mandatory for the determination of treatment modality especially in candidates for monotherapy of permanent prostate brachytherapy.

Patterns of second-opinion diagnosis in oral and maxillofacial pathology

OBJECTIVES

Several studies have documented the beneficial effect of second opinions in diagnostic pathology. Among disease sites, the head and neck can be a particularly problematic area for pathologists, prompting frequent second opinions. However, the effect of second opinion requests made by physician pathologists (PPs) to oral and maxillofacial pathologists (OMPs) has not been well studied and might identify disease and subsites that pose diagnostic challenges. The objectives of this study were to study the referral patterns of PPs to a referral center for oral and maxillofacial pathology and to assess changes in diagnosis following second opinion.

STUDY DESIGN

We retrospectively reviewed 142 consecutive pathology consultation requests over a 2-year period. The submitted report and matched second opinion report were reviewed to extract predetermined demographic, clinical, and pathologic data. Each diagnosis was reviewed to determine if there was agreement, minor disagreement, or major disagreement between the original and the second opinion.

RESULTS

The most common diagnostic categories sent for second opinion were dysplasia/carcinoma, odontogenic cysts, and odontogenic tumors. In the 135 cases where agreement could be assessed, there were a total of 46 cases (34.1%) with differences in diagnostic opinion. Minor disagreements occurred in 24 cases (17.8%) and major disagreements in 22 cases (16.3%). Importantly, major disagreements identified here would have resulted in significant differences in patient evaluation and management.

CONCLUSIONS

This study supports the positive impact of second-opinion surgical pathology for lesions in the maxillofacial complex and supports the role of OMPs in subspecialty diagnostic pathology.

Interinstitutional consultation in fine-needle aspiration cytopathology: a study of 742 cases

BACKGROUND

The importance of interinstitutional consultation (IC) has been documented across a variety of surgical pathology organ systems. However, to the authors' knowledge, few studies exist regarding this practice within cytopathology and specifically within fine-needle aspiration cytology (FNAC).

METHODS

All FNAC cases between September 2002 and January 2007 were reviewed. Original diagnoses and second opinion diagnoses (SODs) were categorized as either no diagnostic disagreement, or minor diagnostic disagreement, or major diagnostic disagreement, and the latter was defined as either a 2-step deviation on a scale of "unsatisfactory, benign, atypical, suspicious, and malignant" or a change in treatment and/or prognosis. Outcome was determined by a review of the electronic medical record.

RESULTS

Among 742 FNAC cases from outside laboratories, there were minor disagreements in 132 cases (17.8%) and major disagreements in 69 cases (9.3%) compared with the SODs from the authors' laboratory. Follow-up was available for 60 of 69 major discrepancies. The SOD was supported on follow-up in 65% of major discrepancies, and the initial diagnosis was supported better in 33% of major discrepancies. In 55% of cases in which the original institution diagnosis was supported better, either no case slides were received for examination or the slides contained material that was considered nondiagnostic by the authors. An SOD prompted a change in clinical management in 32 of 742 patients (4.3%). Aspirates that were most prone to change in management or therapy were from the thyroid (13 cases), neck (soft tissue and lymph nodes; 9 cases), salivary gland (2 cases), and liver (2 cases). Of 60 major diagnostic disagreements, board-certified cytopathologists rendered an SOD in 44 cases, and 75% of the diagnoses were supported better by follow-up, whereas pathologists who were not board certified in cytopathology had only 38% of SODs supported.

CONCLUSIONS

Of 742 FNAC cases, 9.3% had major diagnostic disagreements; and, in 4.3%, patient management and therapy were altered. These results were similar to studies in surgical pathology emphasizing the importance of IC in FNAC. The authors concluded that FNAC IC benefits patient care.

Second opinion pathology in tertiary care of patients with urologic malignancies

OBJECTIVES

The purpose of this study is to evaluate the utility of second opinion pathology in patients who are seen in consultation for urologic malignancy.

METHODS

We retrospectively reviewed the records of all patients who were seen at our institution in consultation for urologic malignancy from August 2002 to April 2008. All available pathologic slides were reviewed by the urologist and pathologist at the time of consultation and compared with the original diagnosis. Discrepant diagnoses were reviewed by at least 2 pathologists. Diagnostic disagreements were graded as minor or major according to the significance of their effect on treatment or prognosis. We report the proportion and types of diagnostic discrepancies and their impact on patient care.

RESULTS

A total of 264 patients were seen in consultation. Of these, 213 had pathologic material available for review: prostate cancer 117 (55%), bladder cancer 83 (39%), testis cancer 5 (2%), renal pelvis or ureteral cancer 5 (2%), retroperitoneal tumor 2 (1%), and kidney cancer 1 (0.5%). Disagreement with the original diagnosis was found in 22 cases (10%), of which 18 (8%) were classified as major, and 4 (2%) were classified as minor. Interventions avoided or delayed, as a direct result of second opinion pathology, were a prostate biopsy in 1 patient, management of metastatic prostate cancer in 1 patient, partial nephrectomy in 1 patient, management of urothelial carcinoma in situ (CIS) in 1 patient, and radical cystectomy in 5 patients. Interventions recommended or performed were radical prostatectomy in 1 patient, and radical cystectomy in another. Additional pathology from subsequent biopsy or surgery was available in 12 of the 22 patients, and the second opinion pathologic diagnosis was supported in all patients.

CONCLUSIONS

A second opinion review of surgical pathology for urologic malignancy can result in major therapeutic and prognostic changes, which can impact patient care. Our results support the review of all pathology by the urologist and pathologist as part of the consultation in patients with urologic malignancy.

Clinical impact of second pathology opinion: A longitudinal study of central genitourinary pathology review before prostate brachytherapy

PURPOSE

To evaluate the clinical impact of pathology review before prostate brachytherapy.

METHODS AND MATERIALS

Original and reviewing pathologists' reports were retrospectively collected from 1323 men treated with prostate brachytherapy between July 1998 and October 2005 at one institution. Statistical analysis was performed pre- and post-January 2002. The clinical impact of pathology review was evaluated.

RESULTS

Gleason Score (GS) change (GS(Delta)) occurred in 25.2% (334) of cases; GS increased in 21.6%, decreased in 2.4%, and diagnosed malignancy in 1.2% of cases. Post-2002, concordance in attributed GS improved, with GS(Delta) of 31.9-20.6%, respectively (p<0.001), and a reduction in the average GS(Delta) (p<0.001). The clinical impact was substantial with management changing in 14.8% of cases.

CONCLUSION

Concordance between the original and reviewing pathologists' GS has improved during the study period. Nevertheless, discordance persists in one of five cases. Pathology review remains essential, if treatment decisions hinge on GS.

PATIENT AND UROLOGIST DRIVEN SECOND OPINION OF PROSTATE NEEDLE BIOPSIES

PURPOSE

We reviewed second opinion prostate needle biopsies that were patient and urologist driven to determine how often an expert opinion resulted in a different diagnosis.

MATERIALS AND METHODS

Of 3,155 prostate needle biopsy consultations received during a 6-month interval 684 were sent at the request of the patient or urologist. A significant change in outside diagnosis was one that could potentially result in a change in therapy or prognosis.

RESULTS

The second opinion was requested by patients (21.6%), urologist (63.9%) and patients plus urologists (14.5%). The distribution of the 684 outside diagnoses was benign in 6.1%, HGPIN in 7.6%, atypical (ATYP) in 29.8% and cancer in 56.5%. In 241 cases (35.2%) a change in diagnosis was rendered upon expert review. We agreed with the majority of outside cancer, benign and HGPIN diagnoses, in contrast to only 36.8% of outside ATYP cases (p <0.0001). Uncommonly did a cancer diagnosis become a benign one or vice versa. Of changes affecting outside cancer diagnoses 73.5% were due to changes in Gleason score. The diagnosis was more likely to be changed when the consultation was requested by the urologist rather than by the patient (41.4% vs 25%, p <0.0001).

CONCLUSIONS

Cases diagnosed as ATYP have the highest likelihood of being changed upon expert review. Urologists should consider sending such cases for consultation to attempt to resolve the diagnosis as definitively benign or malignant before subjecting the patient to repeat biopsy.

Anatomic Pathology Databases and Patient Safety

Context.—The utility of anatomic pathology discrepancies has not been rigorously studied.

Objective.—To outline how databases may be used to study anatomic pathology patient safety.

Design.—The Agency for Healthcare Research and Quality funded the creation of a national anatomic pathology errors database to establish benchmarks for error frequency. The database is used to track more frequent errors and errors that result in more serious harm, in order to design quality improvement interventions intended to reduce these types of errors. In the first year of funding, 4 institutions (University of Pittsburgh, Henry Ford Hospital, University of Iowa, and Western Pennsylvania Hospital) reported cytologic-histologic correlation error data after standardizing correlation methods. Root cause analysis was performed to determine sources of error, and error reduction plans were implemented.

Participants.—Four institutions self-reported anatomic pathology error data.

Main Outcome Measures.—Frequency of cytologic-histologic correlation error, case type, cause of error (sampling or interpretation), and effect of error on patient outcome (ie, no harm, near miss, and harm).

Results.—The institutional gynecologic cytologic-histologic correlation error frequency ranged from 0.17% to 0.63%, using the denominator of all Papanicolaou tests. Based on the nongynecologic cytologic-histologic correlation data, the specimen sites with the highest discrepancy frequency (by project site) were lung (ranging from 16.5% to 62.3% of all errors) and urinary bladder (ranging from 4.4% to 25.0%). Most errors detected by the gynecologic cytologic-histologic correlation process were no-harm events (ranging from 10.7% to 43.2% by project site). Root cause analysis identified sources of error on both the clinical and pathology sides of the process, and error intervention programs are currently being implemented to improve patient safety.

Conclusions.—A multi-institutional anatomic pathology error database may be used to benchmark practices and target specific high-frequency errors or errors with high clinical impact. These error reduction programs have national import.

Improving patient safety by examining pathology errors

A considerable void exists in the information available regarding anatomic pathology diagnostic errors and their impact on clinical outcomes. To fill this void and improve patient safety, four institutional pathology departments (University of Pittsburgh, Western Pennsylvania Hospital, University of Iowa Hospitals and Clinics, and Henry Ford Hospital System) have proposed the development of a voluntary, Web-based, multi-institutional database for the collection and analysis of diagnostic errors. These institutions intend to use these data proactively to implement internal changes in pathology practice and to measure the effect of such changes on errors and clinical outcomes. They believe that the successful implementation of this project will result in the study of other types of diagnostic pathology error and the expansion to national participation. The project will involve the collection of multi-institutional anatomic pathology diagnostic errors in a large database that will facilitate a more detailed analysis of these errors, including their effect on patient outcomes. Participating institutions will perform root cause analysis for diagnostic errors and plan and execute appropriate process changes aimed at error reduction. The success of these interventions will be tracked through analysis of postintervention error data collected in the database. Based on their preliminary studies, these institutions proposed the following specific aims: Specific aim #1: To use a Web-based database to collect diagnostic errors detected by cytologic histologic correlation and by second-pathologist review of conference cases. Specific aim #2: To analyze the collected error data quantitatively and generate quality performance reports that are useful for institutional quality improvement programs. Specific aim #3: To plan and implement interventions to reduce errors and improve clinical outcomes, based on information derived from root cause analysis of diagnostic errors. Specific aim #4: To assess the success of implemented interventions by quantitative measure of postinterventional errors and clinical outcomes and by qualitative assessment by project participants. Funding for this project was approved by the Agency for Health Care Research and Quality in September 2002, and data collection and analysis are ongoing. Over 5000 errors have been collected in the database, and the clinical outcomes of these errors have been tracked. At a national meeting in November 2003, root cause analysis was performed to determine causes of errors. The findings of these root cause analyses have been presented at national pathology meetings and are currently being published.

Institutional pathology consultation

Sun Yat-Sen Cancer Center is the only cancer center in Taiwan. The hospital maintains a policy, and the division of oncology makes a concerted effort to obtain and review pertinent pathologic specimens in all patients who had pathologic diagnosis performed at other institution before rendering therapy. A 1-year retrospective study was undertaken to assess the frequency of discordant diagnosis of our second-opinion pathology slide review and determine its impact on patient care. Discrepancies were classified into four basic categories: A) no diagnostic disagreement; B) no diagnostic disagreement but pertinent information not included, such as tumor size, lymphovascular invasion, perineural invasion, histologic grading, margin status, extracapsular spread in metastatic lymph nodes; and C) major diagnostic disagreement, which was defined as follows; 1) change from benign to malignant, 2) change from malignant to benign, 3) a different type of neoplasm, and 4) change in N and M classification in TMN staging framework. Of 715 cases, a total of 673 (94%) showed no discrepancy. However, 35 of 673 (5.2%) cases failed to offer pertinent information (category B). Major disagreement was found in 42 16%) cases (category C). This study illustrated the fact that second pathology slide review prior to therapy can identify a small group of cases that result in a major change in their therapeutic plan. Admittedly, the review of pathology slides involves additional time and effort for both consulting and referring institutions. It can ensure quality medical care and limit medicolegal liability. As the Association of Directors of Anatomic and Surgical Pathology recommended, second pathology review should be standard practice. It is necessary that our major Pathology Association and Societies adopt a strong position on this matter to influence government or insurance company to pay for this service rendered by pathologists.

Lesions missed on prostate biopsies in cases sent in for consultation

BACKGROUND

There are no reports on how often lesions are missed on prostate needle biopsies.

METHODS

Over a 10-month period, 8/99 to 5/00, 3,251 prostate biopsy cases were seen in consultation.

RESULTS

We identified 87 (2.7%) patients with missed lesions (n = 9 academic hospitals; n = 44 community hospitals; n = 34 commercial labs). Overall, 119 lesions were missed in 87 patients. Missed lesions were as follows: small atypical glands suspicious for cancer (41 lesions in 35 patients), prostatic adenocarcinoma (39 cancers in 32 patients), high grade prostatic intraepithelial neoplasia (HGPIN) (34 lesions in 30 patients), and HGPIN with adjacent small atypical glands (five lesions in five patients)--some men with more than one type of missed lesion. Detection of the missed lesions would have resulted in either: a definite change in care in 15 of 3,251 (0.5%) patients or a possible change in care (bilateral cancer vs. unilateral cancer; HGPIN vs. atypical) in 17 (0.5%) patients. In 21 (24%) of the cases, the slides were seen by at least two pathologists prior to consultation at our hospital.

CONCLUSIONS

Although the number of prostate biopsies with missed lesions in a consult-based population of prostate biopsies appears relatively high (2.7%), the detection of the missed lesions would have only effected a definite change in care in 0.5% of all patients or a possible change in care in another 0.5% of patients. Our data underestimates missed lesions, as the entire specimen was not submitted for review in 41% of cases. Although our incidence of missed lesions gives some indication as to the magnitude of the problem, it cannot be equated with the risk of missing lesions in unselected cases.

Volume and impact of second-opinion consultations by radiologists at a tertiary care cancer center: data

RATIONALE AND OBJECTIVES

Patients with cancer who are referred to a dedicated oncology center usually have undergone previous imaging studies that the oncologists typically desire to have reviewed by radiologists. Such reinterpretations can be complex and time-consuming, yet many institutions do not systematically account for them as part of the total workload. The purpose of this study was to ascertain the numbers and types of second-opinion consultations performed by radiologists at a tertiary care cancer center, and to assess their effect on work volume.

MATERIALS AND METHODS

A survey of referring clinicians was undertaken to evaluate the numbers and types of second-opinion consultations requested of radiologists at the Dana Farber Cancer Institute during a 12-month period. Consultations included review of studies from outside institutions, and cases from Dana Farber in which further comparison was needed. The number of consultations requiring additional tumor size measurements was tallied. The mean daily number of new studies interpreted by radiologists was used as a benchmark of work volume.

RESULTS

Radiologists performed 4,664 consultations during 254 workdays, interpreting a mean of 18 additional studies (range, 4-42) per day as a result of referrals for second opinion. These included 3,638 (78%) cross-sectional studies (ie, computed tomographic [CT], magnetic resonance [MR], and ultrasound [US] studies), 674 (14%) mammograms, 220 (5%) plain radiographs, 132 (3%) nuclear medicine scans, and one galactogram. Of the 4,664 consultations, 1,306 (28%) were performed to obtain tumor measurements, many of these involving five to 10 bidimensional calculations per study. A mean of 101 new examinations per day was performed by radiologists during the same 12-month period, including cross-sectional studies (CT and US scans) (56%), plain radiographs (34%), and mammograms (11%). MR imaging was not performed.

CONCLUSION

Second-opinion consultations increased the average daily work volume by 18%. This has implications for workforce, as well as for compensation in terms of relative value units and finances for this previously unquantified service.

An analysis of the impact of pathology review in gynecologic cancer

PURPOSE

To analyze the impact of pathology review in gynecologic malignancies.

METHODS AND MATERIALS

For all new gynecologic patients seen between December 2, 1993 and January 4, 1996, we conducted a retrospective chart review to determine if a pathology review by the institute's consultant pathologist changed the diagnosis, and if so whether the change altered patient management. A total of 514 patients were seen, of whom 120 had cervical cancer, 226 had endometrial cancer, 122 had a primary ovarian or peritoneal malignancy, 9 had a vaginal malignancy, 28 had vulvar cancer, and 9 had a miscellaneous gynecologic malignancy.

RESULTS

On pathology review the diagnosis changed for 200 of 599 specimens (33%). This altered management for 63 of 514 patients (12%). For patients with cervical cancer, the grade of tumor was the main change in pathologic diagnosis, with occasional change in the presence of lymph vascular invasion. These did not translate into patient management alterations. Eight patients (1.5%) had management alterations. The changes in depth of invasion and vascular invasion altered management for 3 patients. Changes in pap smears resulted in two management alterations, and changes in histologic diagnoses altered management for 3 cases. For endometrial primaries the changes in pathologic diagnosis included grade, depth of invasion, and the presence of cervical involvement. This did alter management in 40 cases (8%). For the ovarian malignancies, the main changes were grade, extent of disease, or histologic classification, some of which (10 patients, 2%) resulted in altered management. One patient with a vaginal lesion had the diagnosis changed, which did alter management. Of the patients diagnosed with vulvar cancer, the pathologic diagnosis changed for 11 patients. This included changes in grade and depth of invasion. This altered management of 2 patients. The remaining miscellaneous gynecologic malignancies had only two diagnosis changes that altered management.

CONCLUSIONS

Pathologic review of gynecologic malignancies is justified as it can alter patient management. In addition, the process facilitates cooperation of the multidisciplinary team and provides a valuable educational forum to enhance patient care.

Failure-free survival following brachytherapy alone or external beam irradiation alone for T1-2 prostate tumors in 2222 patients: results from a single practice

PURPOSE

To evaluate failure-free survival (FFS) for brachytherapy (BT) alone compared to external beam radiotherapy (EBRT) alone for Stage T1-2 Nx-No Mo patients over the same time period by a single community-based practice in the prostate-specific antigen (PSA) era.

MATERIALS AND METHODS

The database of Arizona Oncology Services (a multiphysician radiation oncology practice in the Phoenix metropolitan area) was reviewed for patients meeting the following criteria: (1) T1 or T2 Nx-No Mo prostate cancer; (2) no prior or concurrent therapy including hormones; (3) treatment period 12/88-12/95; and (4) treatment with either EBRT alone or BT alone ((125)I or (103)Pd). This yielded 1527 EBRT and 695 BT patients; no patients meeting the above criteria were excluded from analysis. Median follow-up for EBRT patients was 41.3 months and, for BT patients, 51.3 months. Patients were not randomized to either therapy but rather received EBRT or BT based upon patient, treating, and/or referring physician preference. PSA failure was defined according to the ASTRO consensus guidelines. The median patient age was 74 years for both groups.

RESULTS

Failure-free survival at 5 years for EBRT and BT are 69% and 71%, respectively (p = 0.91). For T stage, no significant difference in FFS at 5 years is observed between EBRT and BT for either T1 (78% vs. 83%, p = 0.47) or T2 (67% vs. 67%, p = 0.89) tumors. Analysis by Gleason score shows superior outcomes for Gleason 8-10 lesions treated with EBRT vs. BT (5-year FFS 52% vs. 28%, p = 0.04); outcomes for lower grade lesions (Gleason 4-6) when analyzed by Gleason score alone do not significantly differ according to treatment received. Patients with initial PSA values of 10-20 ng/dL have an improved FFS with EBRT vs. BT at 5 years (70% vs. 53%, p = 0.001); outcomes for patients with initial PSA ranges of 0-4 ng/dL, of > 4-10 ng/dL, and > 20 ng/dL did not differ significantly by treatment received. FFS was also determined for presenting Gleason score/PSA combinations; all Gleason combinations in the initial PSA range >10-20 ng/dL had superior outcomes with EBRT compared to BT, and this reached statistical significance for Gleason scores of 2-4 (72% vs. 58%, p = 0.026), Gleason 7 (67% vs. 28%, p = 0.002), and Gleason 8-10 (63% vs. 23%, p = 0.05).

CONCLUSION

In our patient population, either EBRT or BT appear equally efficacious for patients with T1/T2 disease with Gleason scores </= 6 or PSA </= 10 ng/dL. Patients with presenting Gleason scores of 8-10 or PSA > 10 ng/dL (but </= 20 ng/dL) appear to fare significantly worse with BT alone compared to EBRT alone. Neither EBRT nor BT alone was particularly effective for patients with a presenting PSA > 20 ng/dL, as would be anticipated from the significant risks of occult distant metastasis in this group. To our knowledge, this is the first report comparing the outcome of EBRT and BT treatment in patients treated concurrently by a single group, and these results, achieved in a community-based practice, compare favorably to data from academic centers regarding external beam, brachytherapy, or surgical outcomes and should be generalizable to the community at large.